|L-R, Antonio J. Vargas; Elaheh Atai, BE; and David Stiles, CBET, manager of biomedical engineering; check out an infusion pump.|
Just as smart health care institutions must stay up to date on the latest patient care techniques and medical technologies, they also must pay attention to current business trends. Today’s buzz can become tomorrow’s requirements, whether due to patient demand, competitive pressures, or regulatory needs. The budgets, cultures, and sizes of health care organizations often prevent them from implementing changes overnight. Therefore, smart institutions also must act early.
Acting before a deadline—or even better, before a deadline has been imposed—allows a hospital to implement changes on its own terms, to begin realizing the benefits early, and to become recognized as a leader. Long Beach Memorial Medical Center (LBMMC), Long Beach, Calif, is seeing these benefits now as the hospital implements a number of initiatives designed to prepare the facility for tomorrow’s demands.
The 750-bed hospital is part of the MemorialCare Health System in California. MemorialCare medical centers also include the Anaheim Memorial Medical Center, Miller Children’s Hospital in Long Beach, Orange Coast Memorial Medical Center in Fountain Valley, and Saddleback Memorial Medical Center in Laguna Hills and San Clemente.
Early Shoots of the Environmental Movement
One of the bigger and more visionary programs undertaken by the biomedical team at LBMMC has been its green effort. While many institutions are just now beginning to consider green initiatives, in part to respond to today’s heavy focus on environmentally friendly policies, LBMMC is beginning to see the benefits of conservation efforts that began years ago.
“The decision for our medical center to start conservation efforts did not come overnight, but rather, evolved over the years as a result of California being one of a few states proactively involved in the green movement,” says David Stiles, CBET, manager of biomedical engineering for LBMMC and Miller Children’s Hospital. More recently, energy challenges, environmental concerns, and changes in the way the medical center delivers health care to the community have intensified the environmental program.
Stiles notes the first real steps the department took were to closely plan and assess new equipment. At the time, the facility’s physiological monitoring systems required replacement in order to integrate them with the conversion to electronic medical records (EMR) as well as to meet HIPAA requirements, and its telemetry systems needed to be updated to accommodate changes in the wireless spectrum. Advances in PC-based medical devices were occurring rapidly and needed to be managed.
As the biomedical engineering department faced replacing an aging 12,000-plus medical device inventory, the team realized that energy costs and the environmental impact of future devices would need to be considered in any new purchase. “Just after 2000, we were aware that we would have to specify equipment that was capable of storing and transmitting data, that was energy efficient, and that could be upgradeable through standardization of the fleet,” Stiles says. He notes the time was right to focus efforts on waste reduction, disposal, and energy-efficient equipment acquisition.
Waste reduction, particularly electronic waste (e-waste), has been one of the more difficult initiatives to undertake. It includes the disposal of non-computer e-waste such as physiological vital signs monitoring, lab instrumentation, large unique medical devices, and other equipment that does not fall into the category of easily disposed, computer-style hardware.
“The design of most electronic equipment disposal programs in California did not include devices used in health care facilities and other large businesses employing non-computer-based equipment,” Stiles says.
Because of the difficulty in finding companies that can dispose of the material in a cost-effective and/or environmentally friendly manner, and to increase efficiency, the biomedical department has learned to extend the life cycle of equipment where possible, such as through relocation or donation.
Stiles describes LBMMC’s approach as a work in progress. The facility has developed solutions through the observation of others, reviews of current state and local statutes, and the creation of partnering opportunities with local and regional businesses. In this way, the facility is improving its current e-waste system. It has already found an alternative to shipping the waste in prepared shipping containers, which has resulted in additional expenses, but the biomed department plans to store and separate the waste to take advantage of bulk savings. The team is currently in the process of trying to find available space in which to accomplish this work.
Not all steps have been so challenging, however. Far easier to accomplish was the initiative to reduce or contain rising energy costs through energy programs developed in cooperation with local utilities. Resulting rebates and returns on investment helped provide motivation for these and other efforts.
Color Me Green
“The main benefit, in my opinion, is cost savings achieved by conserving energy,” says Antonio J. Vargas, a BMET at LBMMC. He cites the positive effect on the environment as a close second. Most of the green initiatives bring both benefits.
For example, the digitization of patient information through EMR and the subsequent elimination of paper waste saves not only trees but also energy. Simply not having to shred patient documents reduces energy and associated salary costs, Vargas notes.
The greatest cost savings from the hospital’s perspective have resulted from the improvement in plant operations and the methods of monitoring and containing both the building operations and its unique environments. The effects are subtle but noticeable when comparing energy levels year over year. Benefits are visible when the level of energy use does not increase as rapidly as growth or when waste levels remain stable over time.
From the biomedical perspective, the upgrade to next-generation PC-based monitoring systems has generated the greatest cost savings. “Not only were we able to reduce the power needed to operate these devices, in many cases we were able to specify and purchase equivalent devices, such as PCs, LCD displays, printers, and other equipment, at a fraction of the medical device vendor’s costs. This two-for-one advantage was an unexpected benefit in our going green process,” Stiles says.
The cost savings in energy returns, however, has been offset by the increase in e-waste disposal costs. “We know that soon we will see a net increase in the combined process, but more development and involvement by the other support services is needed to reach the maximum benefit,” Stiles says.
He estimates that the hospital will see this maximum benefit over the next 5 to 7 years as greater advances and improvements in recycling, equipment design, and longer life help to ease the burden on the biomedical department specifically, and the medical center as a whole.
“To provide a distinct example, consider the size, weight, and energy consumption of a diagnostic ultrasound machine manufactured today as compared to 8 years ago,” Stiles says. “Or consider the RoHS-compliant electronic devices that can be virtually broken down into environmentally safe components during the recycling process.”
These benefits and any possible others are used to gain the support of involved parties, from management to various departments. Buy-in, however, was not difficult to achieve. “As biomed technicians, we all have the full support of our management and full access to the resources we need to accomplish this goal,” says Elaheh Atai, BE, a BMET II at LBMMC.
“The key approach that our department took with the care areas in the medical center was that any improvement on waste, energy, and the physical environment would result in better patient outcomes and staff workflow,” Stiles says. Positive results generated more good will.
“As we flow outward to other departments, I perceive their response as positive,” Vargas says, noting that he has heard few negative comments about changes in upgrades and the standardization of medical equipment. “The employees work with biomed to make the transition easier,” he says.
And the employees benefit, too. For instance, as biomeds replaced the CRT-based displays in physiological monitoring central stations and telemetry monitoring stations with energy-efficient LCD displays, less heat and more space made for a more comfortable working environment. “Everyone knew in some degree that any improvement in the environment would result in a positive outcome in our medical facility,” Stiles says.
Time and Training
The cooperation has contributed to a smoother workflow, though the program has not been without its challenges. The biggest investments were spent in time and educational requirements.
Initially, the changes created more work for the biomed department. “At the beginning, there was more work to be done because of the additional steps we needed to take to install and check all the new equipment,” Atai says.
|Estelito Delmundo, CBET, Long Beach Memorial Medical Center, troubleshoots an anesthesia machine.|
But in the long run, both Atai and Vargas believe the workflow will become easier. Periodic maintenance is not expected to be significantly impacted. “Standardization of equipment adds consistency to the workflow, since it helps out with training,” Vargas says. It also reduces the spare parts load, better establishes the energy load placed in the care areas, and reduces the space needed to store the parts inventory.
Education is equally beneficial but also equally challenging. “Education and time for it for all employees of Long Beach Memorial Medical Center is the most challenging aspect of the program due to the need for constant training and education for new-hires and resources,” Atai says.
Vendors must participate too. “Manufactures have to educate us on their product design to ensure that it meets our specifications,” Vargas says.
According to Stiles, education among the department, staff, and management has brought a stronger commitment, especially during these times when energy costs are in the forefront. The biomedical engineering department has worked with the various medical center services, leadership, and manufacturers to identify and solve relevant problems.
The department has worked especially closely with IT, particularly on equipment specifications, communication standards (HL7), and e-waste disposal collaborations. The biomed team also worked with the medical center to adopt the new state environmental laws enacted to control hazardous e-waste and energy management.
“We became acutely aware of the rapid changes in energy and waste-management regulations and initiatives, especially from the state of California, which was enacting statutes that were comparable with the more stringent standards established by the international community,” Stiles says.
In its pursuit of environmentally friendly practices, the hospital has positioned itself as a leader. “I would like to see our facility be one of the first hospitals going green and, followed by that, have other facilities look to us as their role model,” Atai says.
The initiatives currently in place have been in development since 2000 and have been constantly modified in response to research and results. “Applying research, learning from our mistakes, and constantly tweaking our green program has allowed us to make a difference in our medical center’s environment,” Stiles says.
“As we establish an environmental friendly system, we can help other medical institutions follow our example, and even slow down global warming,” Vargas says.
Pumping Toward Perfection
A less global but no less important goal is the reduction of errors in medication delivery. A hospitalwide initiative at LBMMC focused on providing safe drug delivery to patients. The effort resulted in the installation of a drug safety software library on 1,500 pumps, including roughly 1,200 infusion devices from Hospira Inc, Lake Forest, Ill, and 200 syringe pumps from Medfusion Inc, Raleigh, NC.
“It has been a process going on for some time in the MemorialCare medical centers and was something that was going to be required eventually,” Stiles says. “We decided to go ahead, get on board now, and start the program.” Over a period of 18 days, all of the pumps were removed from service for software and hardware upgrades and wired into the hospital network to enable quality assurance report downloads.
Similar to implementation of the green initiative, the workload associated with this program initially increased but will decrease over time. Stiles estimates that to accomplish the conversion, an extra 160 hours to 180 hours of additional work were required of biomeds. “We had eight-and-a-half full-time employees at that time, and I had to divert a lot of manpower over to the conversion process, so it worked a little tight, and there was a lot of catch-up performing regular functions,” he says.
With the installations complete, the biomeds’ time will be reduced to preventive maintenance and report extraction. The team plans to extract reports from only 25% of the pumps. “It’s impossible to extract reports from every pump in-house, but 25% is a good representative sample for annual or semiannual reports,” Stiles says.
Here too, biomeds had to work closely with IT. “We found that under the current system of setup and downloading of programs, we did not have IT address licenses and had to make changes to configure all the pumps and download the drug libraries,” Stiles says. “We worked closely with IT to accomplish that and to speed up the process of getting new pumps downloaded with libraries.”
WOW: Workstations On Wheels
The biomed department is also working closely with IT on a third initiative: MemorialCare 21, or MC21. Intended to improve patient care and environmental friendliness, MC21 is the conversion of the patient chart to an EMR. Six years in the making, the program went live in LBMMC mid-July; its sister hospital, Saddleback Memorial Medical Center, went live last year.
“All patient information and mid-discharge transfer, medication ordering, dietary ordering, and scheduling of procedures and tests are electronic,” Stiles says. Bedside monitoring now connects to the EMR, uploading vital patient data to the electronic chart. Workstations on wheels—or WOWs—capture and display information.
One challenge has been securing the complete transfer of frequently requested data. “If scheduled to transfer every 15 minutes, the data will not always show up, so the physician will have to enter some vital signs manually,” Stiles says.
Interfacing is another issue. The effort to prepare the interfaces requires some time. LBMMC’s biomedical engineering department needed to spec out new equipment to be sure it had the appropriate data ports and, at a minimum, the ability to handle HL7-compliant data. The effort coincided with the green program so that new devices were evaluated against all of the criteria.
One of these requirements was the ability to interface with the Epic EMR program. For some devices, creative solutions were needed. For instance, a fetal monitor from one vendor required medical interfaces from another vendor to integrate with the Epic EMR.
The IT department and the administration conducted research before selecting the Epic Systems Corp, Madison, Wis, EMR system, factoring in testing, literature, and actual end users. “That process took 3 to 4 years itself and was outside the scope of biomed,” Stiles says.
Now that the system has gone live, the facility is learning it needs to adapt its wireless system. “Once the system went online and all the clinicians started using the wireless workstations, we started seeing a slowing down of the wireless system in the hospital,” Stiles says.
IT has been busy troubleshooting the problem, which has impacted systems such as the biomed department’s computerized maintenance management system (CMMS). “We have a computerized maintenance management program in individual laptops for clinicians, and when Epic went live, the system slowed down dramatically. Now, we are trying to find adjustments to speed up the CMMS program,” he adds.
The information will be used to smooth the conversion of other hospitals in the system. Orange Coast Memorial Medical Center is slated for the program next year. The two remaining facilities, Anaheim Memorial Medical Center and Miller Children’s Hospital, will follow. Eventually, all health care institutions will have to make the conversion to the EMR as HIPAA requirements take effect.
“Under the HIPAA guidelines in the Senate, for reimbursements to occur, most hospitals will have to convert to the EMR, so we started the plan several years ago,” Stiles says.
Acting before the deadline—whether improving environmental policies, medication delivery efforts, or medical technology—has allowed LBMMC to implement the changes on its own terms, spend wisely, realize the benefits early, and become recognized as a leader.
Renee Diiulio is a contributing writer for 24×7. For more information, contact .